A. Problem Analysis

1. What was the problem before the implementation of the initiative?

Mental disorders are an abnormality of mind. The patients cannot control their thoughts, emotions, perceptions and behavior. They may have aggressive behavior which is dangerous for other people, properties, community’s peace, or themselves. The causes of mental disorders is complicated, perhaps they stem from chemical imbalances in the brain, and stressful life events. The treatment is to use bio-psycho-social model and patients’ efficient revival which spends a period of time that increases amount of chronic patients. The statistic of mental disorder in Bangkok has increased from 229,652 in 2008 to 297,090 in 2012 (29.37%). Schizophrenia creates complications in treatment and risks to repeated exacerbation; 70 persons in a year is an average of closely taking care.
There are many varieties and differences in economy, society and living in Bangkok. The emulation and pressures are high. Most of the people come from other areas which make them have less connection; those are factors of stress for schizophrenic to easily recur and they usually come back with severe symptoms. They might feel those are their weakness, lack of self-confidence, decrease self-value, cannot work and cannot take care of themselves. Their families have to take them to doctors. However family’s members have to go out for work so they have no time to look after the patient. That is why schizophrenics are often left at the hospital, welfare, or some of them are vagrants and finally the vagrants harm other people.
From the survey of the Mirror Foundation; a private organization working for social development, found that there were 3,140 public-living-people in Bangkok. The mental patients ware 22 percent, they were homeless people. Some of them had aggressive behavior, rampage, or harass. The old-stuff collector splashed bathroom cleaner to people, the schizophrenic stabbed a student with knife, the tribal mother killed her child, the schizophrenic suicide in public; those are recent news. These patients can live in the society if there is someone to take care of them properly.
A health service for mental patients in Bangkok emphasizes hospital treatment. After treatment the patients go back home, their families have to watch over them. Aftercare services focus on only the body, not the mind, because there are few psychiatric staff; not enough for as large a city as Bangkok. Those make the families receive less help from experts.
When the mental patients make any trouble in society, policemen have to deal with these situations and take the patients to doctors. Nowadays the policemen cannot efficiently handle because they have a lots of work to do and a lack of knowledge and skill in emergencies. So, taking patients into a treatment system is inefficient.
If those problems are not solved, the patients will lack efficient treatment and they may cause wider social problems. The process of mental health service is important.

B. Strategic Approach

2. What was the solution?

The Somdet Chaopraya Institute is the first tertiary mental hospital in Thailand. It is in Bangkok and has provided services for 125 years. Originally the hospital cured referred-patients, nowadays its missions have changed to prevent mental diseases, standardized treatment, and continued rehabilitation.
The ‘Improving Urban Psychiatry Service in Bangkok’ project changes working concept from ‘defensive’; cure in hospital, to be ‘offensive’ into the community. This project focuses on self-care of the patients. It requires corporations from every related department. It is the summary of the lesson about recurred of severe schizophrenic by treatment system improvement inside the institute, and visit patients at their homes for after care service by experts.
The working concept changing from ‘defensive’ to ‘offensive’ into the community has to be supported by the institute’s executives, Bangkok Health Department’s executive; control public health centers which are primary infirmary in Bangkok, institutes, network organization, and people in the community. The patients should well take care themselves. This project supports family and public health networks in the community to look after patients to live with dignity and respect. The methods are;
‘Offensive Taking Care’ uses the public health’s volunteers to look after patients to live well in the community by giving knowledge how to look after patients correctly, how to observe, assess, and first-aid, and find new patients or old patients for any remedies.
‘Confederate’ is the corporation in executive level between the director of Somdet Chaopraya Institute of Psychiatry and Bangkok Health Department which manages 68 public health centers in Bangkok. The two executives realize the problem so they agree to regulate corporate policies to look after psychiatric patients in Bangkok. The workers adjust their attitudes to work for patients to continue in treatment. This method starts with psychiatric treatment training, getting familiar with patients and nurses, after care service, and holding seminars for unity and smoothly corporate.
‘Collaborate’ is a comprehensive schizophrenic treatment. They include prevention, cure, follow-up, and referral; since healing in the institute until discharge. After that, the patients will be referred to local public health centers to follow at home; the psychiatric nurse is a consultant. The patient will be treated by psychiatric nurses for appropriate treatment while they are in the institute. After leaving, the psychiatric nurse cooperates all information and treatment plan with home visit nurses and community nurses. They all use case conference for efficient treatment. The modified psychiatric system will be developed for continued treatment of patients until they can take care of themselves and their families. The patients will be supported to join in community’s activities and seek for jobs.
‘Participate’ is used for complicated treatment for schizophrenics. Improve the case-by-case handbook for after care service to create standardized treatment both in the institute and after discharge. Curriculum is developed for training. Nurse training for the community working concept and importance of home-visiting. Nurse training for more skills and knowledge about schizophrenia. Giving knowledge about observing, follow-up, and evaluating the patients to public health volunteers.
‘Create communication ways via departments’ includes telephone, fax, and social network; line, Facebook. The information and treatment can be consulted for efficiency. It includes a hotline (1323) for direct consultation between patients and psychiatric experts.

3. How did the initiative solve the problem and improve people’s lives?

The offensive working emphasizes creating efficient members to look after patients, it needs networking. The networks include public health centers, policemen, emergency medical officers, and public health volunteers.
This project helps mental patients in Bangkok to get the standardized and comprehensive treatment. The public health centers create higher efficiency in treatment and follow-up. The policemen and emergency medical officers are trained to refer the schizophrenic and have more understanding in treatment and referring.
After this project, the schizophrenic could stay home longer; 86.92 percent of patients could stay more than 3 months at home. The patients’ symptoms kept calm for 85 percent of the time. Their qualities of lives index are in middle to high level. The burdensome feeling of family was decreased in middle to less level for 96.66 percent. Recurring statistics in the institute decreased from 65.38 to 11.53. The public health networks had 12 public health centers which were successful in assessment of standard care for psychiatric service. There were 2 more psychiatric centers. 17 Ruk Jai associations were founded, they were created by public health volunteers. 35 units of policemen and emergency medical officers were trained.

C. Execution and Implementation

4. In which ways is the initiative creative and innovative?

The strategies for mental health in the community have been improved in the last 10 years, especially in Bangkok where people’s lifestyles are very different. Since the process, the advantages and disadvantages are analyzed. There are important strategies;
Cooperation between departments. In 2005, the director of Somdet Chaopraya Institute of Psychiatry did a summary and presented the problems of schizophrenia in Bangkok to the director of the Bangkok Health Department. At that time, the media and society focused on patients who harm others, it was an important factor to make the directors realize the issue and how to solve problems. The staff was empowered by changing their attitudes via seminars, training, and sharing opinions to create the same working concepts. The staff had ‘confederate’ and realized their importance.
Comprehensive development for taking care of schizophrenics. In 2006, the institute’s staff and Department of Health set taking care of patient’s system from the hospital to the home. It was ‘collaborated’ and making plan by every department. They realized their roles and gave equal importance to all of them. In 2007, the institute and the public health centers ‘participated’ systematically. The taking care of patients after discharge system was created. The institute and the public health centers set follow-at-home system which had institute’s nurses, community psychiatric nurses, and the public health centers’ nurses planned the individual look after plan for each patient. The information transferred in the team, it made a good relationship between patients and visit-home teams. In 2010, the schizophrenic’s rehabilitation was created and supported many activities in the community. The psychiatric referred system for policemen and emergency medical officers was developed in 2013.
Documents and handbooks development. The psychiatric experts in the institute led production of handbooks. The staff; institute’s and Health Department’s, in many events shared their information, suggestions, assessment, and test before published and trained. The project needs many people in many fields; the handbooks have to be produced for their understanding for efficient treatment.
Training and educated. The institute was a lead to train visit-home nurses and the volunteers. The institute supported scholarships in psychiatric nursing for 4 months course for the public health center’s nurses. The institute provided training for patient screening; psychiatric taking care, primary symptom assessment, and rehabilitation were trained for the volunteers. The volunteers could primary find, observe, evaluate, and taking care of schizophrenic. The policemen and emergency medical officers were trained for evaluating and referring patients safely.
Two-way communication. The community psychiatric nurses took responsibility to coordinate between the institute and public health centers. The nurses were also supporters and consultants. Moreover, they also gave patients’ information back to the institute for more convenience and made confidence of taking care of schizophrenics.
From the above strategies, they could summary as the success requires ‘confederate’ for the same goal. It needs ‘collaborate’ for making plan as a part of the plan. The last one is ‘participate’ in each own duty for schizophrenic’s lives.

5. Who implemented the initiative and what is the size of the population affected by this initiative?

This project was the cooperation between Somdet Chaopraya Institute of Psychiatry and Bangkok Health Department. They took part in planning for problem solving. The related departments are;
The Somdet Chaopraya Institute of Psychiatry took care of patients while they were in the institute. The patients were taken care by the multidisciplinary team, the team referred patient’s information to the public health centers for house-following. The community psychiatric nurses followed-up after discharge every 3 months for a year. The nurses made treatment plans and gave advice for the public health centers’ nurse if there were any problems. The patients got continued treatment from experts.
The public health centers took a role as planning treatment and patient’s rehabilitation with the nurses from institute and the community. They did symptom evaluation and gave suggestions every month to the family about taking care of the patient. The centers were coordinators in transferring of patients’ information, problems, and help.
The public health volunteers were backbones in the community to regularly observe and assess patients. The rehabilitation activities were created via the Ruk Jai Association. The associations were NGOs which had groups of volunteers to look after patients’ mental health. The public health volunteers were coordinators between the schizophrenic’s family and visit-home nurses for the efficient taking care of patients.
The policemen and emergency medical officers helped to refer execrative schizophrenics, or uncooperative patients to the institute. The volunteers gave information and policemen prevented any harm from uncontrolled schizophrenics. The 2 areas were proceeded and 7 more in Bangkok were planned.
The schizophrenic’s family needed to be the main caregiver. The family had to support for the continued and correct treatment, helped the patients to adapt themselves, helped them to take care themselves, social living, and working with others.

6. How was the strategy implemented and what resources were mobilized?

This project is the policy of two executives, so the budget came from both two. The institute’s budget was used for 40 percent for training every officer about taking care of schizophrenics, seminars between Somdet Chaopraya Institute of Psychiatry’s nurses and public health’s nurses for annual plans, and producing lessons for handbooks. The other budget was from Health Department for 60 percent for the fundamental training, developing the standards of patient services in Bangkok, demonstration the psychiatric working of the public health centers to be modern. The Mental Health Department supported 10-15 scholarships for 4 months about mental health every year. The Community Department of Health took part of providing food for patients’ activities.
The human resources were from Somdet Chaopraya Institute of Psychiatry; nurses, community psychiatric team, and multidisciplinary team. The team that followed patients to home was visit-home nurses, and volunteers who were important for community activities for patients.
Any resources were 1.Operational manuals; individual management for house visiting, standards for taking care of complicated schizophrenics, standards of mental services in Bangkok, mental health awareness guide for services, lists of mental health network in Bangkok, mental rehabilitation guide, schizophrenic’s society in the community for nurses, guidelines of schizophrenic’s activities for Right Support Volunteers; those were from knowledge in real events, they were made and published to every officers. 2. At-home assessments; Brief Psychiatric Rating Scale (BPRS), Quality of Life (QOL), Burden of Care; those were efficient and tasted reliability. 3. Communicate technology; Facebook, Line; were used for convenience, speed, and informal news of the institute.
The very important health process are treatment, rehabilitation, and prevent people from mental sickness. The resource has to be up-to-date and to be used appropriately. The users are medical and health officers, and people. The processes of research, development, and management of knowledge are used for real usages.

7. Who were the stakeholders involved in the design of the initiative and in its implementation?

In the past the Somdet Chaopraya Institute of Psychiatry and Bangkok Health Department were separate. Each department worked on its own without any connections. After this project, the cooperation between two departments went well and smoothly. The two executives had the same thought about mental services extension. Those two officers have a good relationship which promotes good work.
After developing the comprehensive system for taking care of schizophrenics, the standardized services were created; intensive cure in hospital, watch over at home, rehabilitation, find new patients, and emergency refer patients. The looking patients after was wide to the public health centers, the schizophrenic could spend less time than going to hospital. 2 more centers were opened; they got level of standard of mental patient services for 12 public health centers (17.65 percent). There were 158 new patients. The 106 un-continued patients were back for treatment and 405 of rehabilitation.
The development in producing documents and handbooks created 8 new guidebooks e.g. guides for taking care of schizophrenics both inpatient and visit-home, standards of mental services, mental rehabilitation activities guidebook, mental health awareness guide for services, and lists of mental health network in Bangkok. This knowledge can be used in real situations; they came from the summaries of working and taking care of patients.
From the training strategy; the Somdet Chaopraya Institute of Psychiatry is an educational institution, the training for more knowledge and skills in psychiatric field were held for every officer. The 104 nurses from the public health center participated in special nursing for mental health; that made enough nurses for every center in Bangkok for care psychiatric patients. The 1145 volunteers from the Ruk Jai Association participated in the training also. Before this project there were no psychiatric officers in the centers. All nurses in the institute got guidelines and adjusted attitudes about community work.
The two-way community created more convenience between departments. The telephone, fax, social network; line, Facebook, e-mail, 1323 hotline of mental consultation were made to get advice from experts.

8. What were the most successful outputs and why was the initiative effective?

The assessments of the project were made every year. The assessments came from patients and families assessment for service, percentage of burden feeling of caregiver, psychiatric symptom level, quality of life of patients in their houses, the period of living home, the quantity of re-cured in the institute, and the satisfaction of patients and families. The details of patients and relatives was collected every 6 months in March and September.
The evaluation within the institute had summaries of every patient and sent the information back to the public health centers’ nurses to improve their treatment. The 90 percent of patients got treatment from multidisciplinary. The remaining 10 percent had to be disposed before finished the course. There was visit-home assessment of the center; it followed patients who were referred to the centers. The processes were letting the center send patients’ information back to the institute every time after visiting, and followed the patients of community mental nurses every 3 months. The 88.47 percent of patients could stay at home; the volunteers took care of them also.
The evaluation of the public health centers was the efficiency of work inside the center according to the standardization of psychiatric service in Bangkok. In the past the centers never worked about community mental health, so there was no standard for mental working. This project aimed the centers to increase their abilities of psychiatric services. The center could be evaluated themselves according to the standards of psychiatric service in Bangkok, the experts would re-evaluate again. The satisfaction of nurse evaluation was provided. The 12 of centers got assessment (17.65 percent) in a good level; the nurses had 96.66 satisfaction about community mental work.
The cooperated evaluation by holding seminars, evaluation, and planning every year which was worker evaluation and presented workings to executives for more cooperation, and also setting working directions to be appropriate for situations, were well supported by workers. The executives emphasized on mental working, and expanded patients’ treatment in every area.

9. What were the main obstacles encountered and how were they overcome?

Setting mental services system for urban people certainly had obstacles. The problems came from urban structures which caused;
The cooperation between departments needed role learning of each department. The problems were attitude of public health service’s nurses. The nurses never worked with schizophrenics, they felt anxious and scared to look after the patients. The good attitude for patients had to be built, and also trained for taking care skills, knowledge, and provided correct knowledge to society via volunteers to reduce prejudices on schizophrenia.
The role changing of the nurses in the institute who never visited patients at their house created the attitude that, the taking care of patients when they were home was not the nurses’ responsibility. It created a feeling of extra work. The meetings and seminars were held to explain and change their attitudes. The nurses could be part of making plan, and the executives of the institute went along with the policies and changed some patients’ treatment for more convenience of the nurses. So the nurses had enough time to visit.
The expertise of psychiatric treatments was one of the problems. The treatment required sensitive techniques for efficiency. The essential regular training, appropriate handbooks, and closely consult for nurses such as telephone, LINE, or Facebook are important. The nurses would treat well with the same standards.
The severe exacerbation of schizophrenics made losing control of themselves a possibility. They might express aggressive behavior and harm other people. The policemen and emergency medical officers had to control the situation and referred them to experts. However, the policemen and emergency medical officers had less knowledge and skill to handle with that case, so they scared to manage the situation. The training and skill development of controlling and referring schizophrenics correctly and safely were held for the officers’ confidence and working security.

D. Impact and Sustainability

10. What were the key benefits resulting from this initiative?

Patients and relatives. There were 405 families who were followed continually when they went back home by the public health centers. The 85 percent of the patients were calm. They could stay at home more than 3 months for 86.92 percent. The recurred statistics decreased from 65.38 to 11.53 percent. Every patient could live their lives with good quality. They could take good care of themselves, so that reduced the burdensome feelings of the family for 96.66 percent. The patients and caretaker had very high satisfaction of the public health centers’ services because they both were helped from the problems correctly. Some of the patients had the ability to work; they could get more money for their families. The families also could work full time; the family’s expense reduced more than 200,000 baht in a year. The amount of patients in the hospital decreased also, the expenditure of curing patients was reduced by more than 800,000 baht per month.
Community. The community had a better attitude of schizophrenia; the people accepted patients to live and cooperated to look after them. That could reduce schizophrenic’s guilt. The community accepts patients’ help in any developing activities in the community. The schizophrenic did not make any troubles. Those reduced the policemen’s and family’s responsibility to referring patients into the institute again. Moreover, the 1145 public health volunteers in the community had trained about taking care of schizophrenics at home. The overall operation showed that the satisfaction of getting knowledge of taking care of the schizophrenic was in middle level of 96.52 percent. When the volunteers could do treatment well, the strength cooperation between the institute and community’s leaders was created. The chances of providing any fields of mental health could be given directly to people, it had many tremendous values. When the schizophrenic could take care of themselves, the family controlled patients’ continued treatment and social living, the volunteers helped the patient to rehabilitation. Those were the most effective way to prevent severe exacerbation.

11. Did the initiative improve integrity and/or accountability in public service? (If applicable)

This project was continually operated by the cooperation between every department’s executives to emphasize the taking care of schizophrenics, and there were policies to support and give budget for this project. The project’s processing system was adapted to each department’s system. Moreover the Department of Health sent visit-home nurses to study more in special psychiatry every year. The hard work of every related officer made the project very successful that represented the good attitudes of nurses, volunteers, community leaders, and patients’ families. Those were keys for sustainability.
The expansion to other department. The institute of Kullaya Rajanagarindra and Srithanya Hospital which are famous psychiatric hospitals in Bangkok, they used this system also. The Somdet Chaopraya Institute of Psychiatry which was the educational institution also used this project for medical students, residents, Thai and foreign psychiatrists to observe and provide psychiatric treatment in the community. For example, the scholars from the World Health Organization, Bangladesh, international trainees in the Community Mental Health from mental health department of Thailand, and governmental officers from Bhutan. The institute presented workings in the 12th HA National Forum 2011, the international symposium 2012. The workings were published as ‘The development of public health center nurses network to care for schizophrenic patients at home’ in the Journal of Psychiatric Nursing and Mental Health; volume 26 issues 2 of May – August 2012. The impact factor was 0.159. This working received the national governmental service award in excellent of service development in 2014 from the governmental system development committee. The schizophrenic community treatment which had cooperation from many departments was network creating. This cooperation for people services can be adapted in other urban societies.
The continued plan for 2015 will increase networks to other psychiatric services for various working strategies and change information with each department. The expectance is, the schizophrenic database will be connected in every area of Bangkok. The cooperation between policemen and emergency medical officers will be provided, especially giving knowledge and skills to manage schizophrenia in emergency cases. The patients should be referred to further treatment safety. In 2016 there is a plan to expand services for schizophrenia to all areas of Bangkok. The purpose is increasing 6 of efficiency public health service center which have psychiatrists to evaluate and find new patients.

12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)

From this project, we learn what was the first thing to do; courage to change working ways for better success without sticking with old thoughts. The cooperation between the related departments is needed. The important factors for taking care of patients were a good attitude and working skills with schizophrenics. The institute started with creating a good attitude and trained for more skills and knowledge for more confidence, more efficiency, and continually. The reliability of officers was important. They had to believe that they could do good things with suggestions or advice from the institute.
The institute knows that, the community is the key factor for taking care of schizophrenics because the community is the closest unit and could help patients more quickly. The patients and families gave reliability to the community for suggestions. The community working should be supported to be effective community for primary help of schizophrenics and their families. This can protect patients from severe exacerbation. Another important lesson is the communication between the institute and the center. The comfortable, fast, and effective communication should be provided for transferring patients’ information and treatment. The patients have to be cured for a long time, difficult problems may occur and require cooperation between every department. This can increase confidence for the public health center and the community that they will not be abandoned.
The thing that we have learnt from the mistakes is not to change working dimensions too quickly. Most public health centers have different efficiency and availability, so the forward moving are different. Trying to change the dimension of work has to be waited until the old basic working is strong. If the basic working is weak, other dimensions cannot be developed. The time is enough required for working adaptation in community mental health to prevent the weakness and tiredness of officers.